Predictors of suboptimal breastfeeding: an opportunity for public health interventions.

BACKGROUND: Sub-optimum breastfeeding significantly contributes to the global burden of disease. Our aim was to identify risk factors associated with suboptimal breastfeeding in Southern Croatia. METHODS: Between February 2008 and August 2009, 773 mother-infant pairs were recruited from University Hospital of Split Maternity Unit. Mothers were interviewed at birth, 3, 6, 12 and 24 months. RESULTS: Ninety-nine percent of mothers initiated breastfeeding but only 2.2% of them exclusively breastfed whilst in hospital. At 24 months, 4.1% of mothers were breastfeeding. Exclusive and any breastfeeding at 3 months was negatively associated with maternal education of 12 years or less, smoking during pregnancy, intention to use a pacifier and in-hospital formula supplementation. In addition, exclusive breastfeeding at 3 months was negatively associated with primiparity, antenatal course non-attendance and not receiving assistance with breastfeeding from hospital staff. Antenatal course non-attendance and discussing infant feeding with a health professional during pregnancy lowered the odds for any breastfeeding at 6 months. At 12 and 24 months, a lower level of education, antenatal course non-attendance and not receiving advice in hospital on feeding frequency was significantly associated with lower odds of breastfeeding. Additionally, intention to use a pacifier was found to be a negative predictor of breastfeeding at 12 months. CONCLUSIONS: Important modifiable risk factors found to be significantly associated with suboptimal breastfeeding include smoking during pregnancy, intention to use a pacifier, in-hospital formula supplementation, not receiving advice from hospital staff on normal feeding patterns, not receiving assistance with breastfeeding in hospital and antenatal course non-attendance.

Essential Workers' COVID-19 Vaccine Hesitancy, Misinformation, and Informational Needs in the Republic of North Macedonia.

The COVID-19 pandemic has resulted in over 5.2 million deaths. Vaccine hesitancy remains a public health challenge, especially in Eastern Europe. Our study used a sample of essential workers living in the Republic of North Macedonia to: (1) Describe rates of vaccine hesitancy and risk perception of COVID-19; (2) Explore predictors of vaccine hesitancy; and (3) Describe the informational needs of hesitant and non-hesitant workers. A phone survey was administered in North Macedonia from 4−16 May 2021. Logistic regression explored associations of COVID-19 vaccine hesitancy with sociodemographic characteristics, non-COVID-19 vaccine hesitancy, previous diagnosis of COVID-19, and individual risk perception of contracting COVID-19. Chi-squared analyses compared differences in informational needs by hesitancy status. Of 1003 individuals, 44% were very likely to get the vaccine, and 56% reported some level of hesitancy. Older age, Albanian ethnicity, increased education, previous COVID-19 diagnosis, acceptance of other vaccines, and increased risk perception of COVID-19 infection were negatively associated with vaccine hesitancy. Results indicated significant differences in top informational needs by hesitancy status. The top informational needs of the hesitant were the freedom to choose to be vaccinated without consequences (57% vs. 42%, p < 0.01) and that all main international agencies recommended the vaccine (35% vs. 24%, p < 0.01).

Protection, promotion and support of breast-feeding in Europe: progress from 2002 to 2007.

OBJECTIVE: To assess progress in the protection, promotion and support of breast-feeding in Europe. DESIGN: Data for 2002 and 2007 were gathered with the same questionnaire. Of thirty countries, twenty-nine returned data for 2002, twenty-four for 2007. RESULTS: The number of countries with national policies complying with WHO recommendations increased. In 2007, six countries lacked a national policy, three a national plan, four a national breast-feeding coordinator and committee. Little improvement was reported in pre-service training; however, the number of countries with good coverage in the provision of WHO/UNICEF courses for in-service training increased substantially, as reflected in a parallel increase in the number of Baby Friendly Hospitals and the proportion of births taking place in them. Little improvement was reported as far as implementation of the International Code on Marketing of Breastmilk Substitutes is concerned. Except for Ireland and the UK, where some improvement occurred, no changes were reported on maternity protection. Due to lack of standard methods, it was difficult to compare rates of breast-feeding among countries. With this in mind, slight improvements in the rates of initiation, exclusivity and duration were reported by countries where data at two points in time were available. CONCLUSIONS: Breast-feeding rates continue to fall short of global recommendations. National policies are improving slowly but are hampered by the lack of action on maternity protection and the International Code. Pre-service training and standard monitoring of breast-feeding rates are the areas where more efforts are needed to accelerate progress.

Effectiveness of the UNICEF/WHO 20-hour course in improving health professionals' knowledge, practices, and attitudes to breastfeeding: before/after study of 5 maternity facilities in Croatia.

AIM: To evaluate knowledge, practices, and attitudes to breastfeeding among Croatian health professionals before and after the United Nations International Children's Emergency Fund/World Health Organization (UNICEF/WHO) 20-hour course. METHODS: Study included 5 of 9 maternity hospitals in southern Croatia, which had completed the UNICEF/WHO 20-hour breastfeeding training course between December 2007 and February 2009. An anonymous questionnaire testing knowledge and practices, and attitudes was distributed to 424 health professionals before training and to 308 health professionals afterwards. Health professionals' attitudes were assessed using the validated Iowa Infant Feeding Attitude Scale. RESULTS: The pre-training response rate was >90%, but only 53% of data were analyzed; the post-training response rate was 69%. Only one-fifth of health professionals prior to training knew that breast preparation in pregnancy was unnecessary, but this increased to 57% after training (P<0.001). The proportion of health professionals who recognized hospital practices that support breastfeeding and signs of poor positioning when breastfeeding nearly doubled after training (P<0.001). The proportion of health professionals correctly recommending immediate "skin-to-skin" contact post-Cesarean section under local anesthesia did not improve significantly, and stratification analyses showed that younger respondents (<36 years) were more likely to support this practice. Although the proportion of health professionals who correctly managed mastitis improved significantly as a result of the training, the proportion of those who after training inappropriately recommended partial or complete cessation of breastfeeding remained high at 47%. The number of staff with positive attitudes toward breastfeeding increased from 65% to 79%, whereas the number of staff with neutral attitudes dropped from 26.6% to 9.9% (P<0.001). Even after training, a substantial proportion of health professionals showed uncertainty in their attitude toward alcohol consumption and breastfeeding. CONCLUSION: The UNICEF/WHO 20-hour course appears to be an effective tool for improving health professionals' breastfeeding knowledge, attitudes, and practices.

Organization or Community-Based Outbreak? Responding to Cases of Meningitis Under Epidemiologic Uncertainty.

Six cases of serogroup C invasive meningococcal disease were identified in Treviso district, Veneto region, Italy between December 13 and 15, 2007. The afflicted patients were found to have attended the same Latin-dance clubs on the same nights, and chemoprophylaxis was provided to potentially exposed individuals. Despite these efforts, 2 cases caused by the same meningococcal strain subsequently occurred in the same area, without any apparent epidemiological correlation to the initial cases. This may have resulted from a failure to neutralize the meningococcal carrier/s. The root cause analysis method applied to public health emergency preparedness was used to analyze the response to this critical incident. The root cause analysis revealed a need to develop regional guidelines for the classification and management of a meningococcal outbreak and for developing risk-communication strategies that include the identification of appropriate channels of communication for differing segments of the population. (Disaster Med Public Health Preparedness. 2019;13:368-371).

Management of meningococcal outbreaks: are we using the same language? Comparison of the public health policies between high-income countries with low incidence of meningococcal disease.

BACKGROUND: Invasive meningococcal disease (IMD) in high-income countries usually occurs sporadically with low incidence and occasionally as small clusters or outbreaks. The WHO guidelines (GLs) for IMD outbreak applies only to African countries with high endemic incidence. Several high-income countries developed their own GLs on IMD outbreak, and we compare their terminology, classification, definitions, and public health interventions. METHODS: National IMD outbreak GLs of the European Union and the Organisation for Economic Co-operation and Development member states were compared. Due to linguistic barriers, 17 out of forty-one countries were selected, and the GLs on the websites of the national health authorities were independently screened by two researchers. RESULTS: National GLs on IMD outbreak were available for 12 countries. All GLs classify IMD outbreak into organization and community based using different terminology (cluster, epidemic, etc.). Two GLs introduce also a third condition of hyperendemic. Definitions, thresholds, and countermeasures vary among countries. CONCLUSIONS: Different definitions of organization and community-based outbreaks and countermeasures are expected because of uncertainties about their effectiveness, and differences between countries in health-care systems and public health policy approaches. Nevertheless, variations in terminology, definitions and countermeasures are confusing and reflect the need for an international standardization.

Compliance With WHO/UNICEF BFHI Standards in Croatia After Implementation of the BFHI.

BACKGROUND: The primary goal of the Baby-Friendly Hospital Initiative (BFHI) is to create conditions in maternity facilities that enable women to initiate and sustain the practice of breastfeeding exclusively. Research aim: This study aimed to determine hospital practices and breastfeeding rates before and after BFHI implementation and assess compliance with UNICEF/World Health Organization (WHO) standards for seven of the BFHI's Ten Steps to Successful Breastfeeding ( Ten Steps). METHODS: Mothers of healthy, term infants ( N = 1,115) were recruited from the postnatal ward of the University Hospital of Split, Croatia, between February 2008 and July 2011 and followed for 12 months in a repeated-measures, prospective, longitudinal, three-group, nonequivalent, cohort study. Breastfeeding rates, hospital practices-including seven of the Ten Steps-and maternal sociodemographic data were collected. RESULTS: Parts of all seven Ten Steps that were assessed improved significantly post-BFHI. Step 3 ("antenatal education") showed the least improvement, whereas Step 7 ("rooming-in"; 2.6% pre-BFHI vs. 98.5% post-BFHI) and Step 9 ("no pacifiers/teats"; 21.8% pre-BFHI vs. 99.4% post-BFHI) showed the greatest improvement. Six months after Baby-Friendly designation, only Steps 7 and 9 were in full compliance with UNICEF/WHO standards. In-hospital, exclusive-breastfeeding rates rose markedly ( p < .001), but no change occurred in breastfeeding rates at 3, 6, or 12 months. CONCLUSION: Full implementation of the BFHI was associated with significant improvement in hospital practices and in-hospital, exclusive-breastfeeding rates, but it did not affect breastfeeding rates postdischarge, emphasizing the vital role of community support. Baby-Friendly Hospital Initiative standards declined rapidly post-hospital designation, indicating the need for regular monitoring and reassessment as well as ongoing, effective training for hospital staff.

Hospital practices and breastfeeding rates before and after the UNICEF/WHO 20-hour course for maternity staff.

BACKGROUND: The Baby-Friendly Hospital Initiative (BFHI) is the most widely promoted program for increasing breastfeeding rates. OBJECTIVE: To evaluate the impact of BFHI training on hospital practices and breastfeeding rates during the first 12 months of life. METHODS: Eighty percent of maternity medical and nursing staff at the University Hospital in Split, Croatia, completed the updated and expanded United Nations Children's Fund/World Health Organization 20-hour course. Seven hundred seventy-three mothers (388 in the pre- and 385 in the post-training group) were included in a birth cohort and interviewed at discharge and at 3, 6, and 12 months postpartum to evaluate hospital practices and infant feeding. Six out of 10 Baby-Friendly practices were assessed using standard BFHI forms. RESULTS: Three months after training was completed, 3 of the Baby-Friendly practices assessed (Step 4, "Initiate breastfeeding within a half-hour of birth"; Step 7, "Rooming-in"; and Step 8, "Feeding on demand") had significantly improved. The proportion of newborns exclusively breastfed during the first 48 hours increased from 6.0% to 11.7% (P < .005). There was no difference in breastfeeding rates at discharge or at 3, 6, or 12 months between the pre- and post-training groups. CONCLUSION: Training of health professionals, based on the BFHI, was associated with significant improvement in some Baby-Friendly hospital practices and initial exclusive breastfeeding rates. A high rate of in-hospital supplementation may partly explain the lack of improvement in breastfeeding exclusivity and duration after discharge. Strong institutional support and commitment is needed to enable full implementation of recommended Baby-Friendly practices.

Infant feeding and cost of health care: a cohort study.

AIM: To compare the use and cost of health care in infants with different feeding patterns. METHODS: Observational study on a cohort of 842 infants born in ten hospitals in northern Italy and followed up to age 12 months. Data on feeding gathered through telephone interviews with 24-hour recall. Data on use of health services reported by mothers and checked against records. Data on hospital cost derived from Disease Related Groups codes. Data on cost of other services obtained from maternal reports and available price lists. RESULTS: At three months, 56% of infants were fully breastfed, 17% complementary fed and 27% not breastfed. Infants fully breastfed at three months had 4.90 episodes of illness requiring ambulatory care and 0.10 hospital admissions per infant/year compared with 6.02 and 0.17, respectively, in infants not or not fully breastfed. They had also a lower cost of health care: 34.69 euro versus 54.59 per infant/year for ambulatory care, and 133.53 euro versus 254.03 per infant/year for hospital care. Higher cost of health care was significantly associated with having a hospital admission and being a twin; cost of health care decreased with each additional gram of birth weight, each month of delayed return of the mother to work after the third month, and each extra month of breastfeeding. CONCLUSION: Lack of breastfeeding and higher use and cost of health care are significantly associated.